Example of treatment flowchart

Example of Doctor Preference of Constipation Treatment Flowchart

Extracted from The Family Practice Notebook

Constipation in Cancer by Scott Moses, MD

1. See Also

   1. Bowel Regimen in Chronic Narcotic Use

2. Causes

   1. Attempt to identify cause
   2. Do not assume Narcotics are always the cause

3. Differential Diagnosis

   1. Bowel Obstruction in Terminally Ill Patient

4. Management: Address each of four factors

   1. See Bowel Regimen in Chronic Narcotic Use
   2. Low intestinal solids
      1. Due to decreased Dietary Fiber
      2. Manage with Psyllium
         1. Avoid in dehydration due to stool impaction risk
   3. Low stool water content
      1. Causes
         1. Dehydration
         2. Slow stool transit time
         3. Decreased intestinal water secretion
         4. Management
            1. Lactulose 30 ml PO q4-6 hours
            2. Sorbitol 30 ml PO q2-4 hours until stool
            3. Glycerin suppositories
   4. Low gastrointestinal motility
      1. Causes
         1. Non-ambulatory or bed-ridden patient
         2. Neurodegenerative disease
         3. Medications
            1. Morphine and other Narcotics
            2. Tricyclic Antidepressants
            3. Scopolamine
            4. Diphenhydramine (Benadryl)
            5. Vincristine
            6. Calcium Channel Blockers
            7. Iron Supplementation
            8. Calcium Supplementation
            9. Aluminum salts
            10. Management
                1. Senna
                2. Bisacodyl
                3. Prune juice
                4. Casanthranol
   5. Decreased gastrointestinal lubrication
      1. Due to dehydration
      2. Management
         1. Mineral Oil enemas
         2. Glycerin suppositories
         3. Dioctyl sodium sulfosuccinate

5. Prevention

   1. See Bowel Regimen in Chronic Narcotic Use
   2. Prevention is much easier than treatment
   3. Administer prophylactic medications with Narcotics
      1. Gastrointestinal motility Stimulant Laxative and
      2. Stool Softener
   4. Example Agent: Pericolace

6. References

   1. Hallenbeck (2000) End-of-life Physician Resources #15
      1. http://www.eperc.mcw.edu
   2. Ross (2001) Am Fam Physician 64(6):1019-26

The Family Practice Notebook: http://www.fpnotebook.com/GI/HemeOnc/CnstptnInCncr.htm